Managing a sentinel event usually consists of the following steps: immediate action, planning the investigation, data collection, data analysis, corrective action plan, and reporting to accreditation agencies. For this assignment, first, review details from the Week 2 and Week 3 discussions, including responses from peers, as well as instructor gradebook feedback. Then, you will focus on the parts below to develop a cohesive plan to address the sentinel event. Address the following in the Executive Summary to CEO template.
Part 1: The Sentinel Event
Summarize the facts related to the sentinel event:
Description of the event
- Staff involved
Discuss the timeline events from initiation of the error through the resolution (will vary depending upon the sentinel event):
When and/or where did the error occur?
When was it detected?
When was it reported and to whom?
- Evaluate procedural errors:
Identify the point in time when the error should have been detected before it occurred.
What part of the process or procedure was missed that contributed to the sentinel event?
Analyze accreditation agency (e.g., OSHA, ACHA, CMS, CDC, CLIA, TJC, AHCA, state agencies) requirements:
Identify which agency(s) would be involved
Define the agency’s purpose
- Discuss the agency’s reporting expectations based on the incident
Part 2: Root Cause Analysis: Fishbone Diagram
Create a fishbone diagram. You will be responsible for creating the CQI Tool (fishbone), completing the tool, copying or taking a screenshot of the completed work, and pasting the completed fishbone diagram into the final document.
If you are unfamiliar with the fishbone, please refer to the Using Quality Improvement Methods for Evaluating Health Care (Links to an external site.) article by Siriwardena (2009).
In addition, as a learning resource, the CQI tool listed below is hyperlinked to the Institute for Health Care Improvement website, which discusses and illustrates an example of the Fishbone. Tools: Cause and Effect Diagram (Links to an external site.)
Part 3: Root Cause Analysis Report
Create a root cause analysis.
Identify the data you would collect to determine the cause.
Give your rationale for choosing the data.
- Identify the probable cause, which may include a process failure, human error, cultural biases, policy error, systems error, technology failure, etc., that may have contributed to the sentinel event. Consider the following as applicable to your chosen event as you complete this segment:
What human factors were relevant to the outcome?
What process errors were relevant to the outcome?
Were there any steps in the process that did not occur as intended?
How did the equipment performance affect the outcome?
- What are the other areas in the health care organization where this could happen?
Did staff performance during the event meet the expectations?
- Develop a corrective action plan that is geared towards eliminating future events.
Explain the steps of implementing the corrective action plan. Consider the following in developing your response to this component:
Identify risk reduction strategies
Improvement of processes or systems
- Communication barriers—for example, discuss the communication breakdown that might have contributed to the sentinel event, or what barriers may have occurred to cause the breakdown in communication (e.g., residual intimidation, reluctance to report a coworker, missing information at time of transition of care, etc.).
Training (e.g., orientation, professional development, cultural competency, skills training, in-service)
Equipment (e.g., technology, maintenance, and updates)
Policies and procedures (e.g., new or revised)
- Describe the monitoring process that will be used to evaluate the success of the corrective action plan.
Analyze the components that may require the reallocation of budgetary resources. Consider the following as applicable to your sentinel event:
Public relations (reputation leading to decreased revenue)
Equipment and supplies
Training and education
Patient-centered communication methods (e.g., informed consent, procedural education, patient involvement [identify or mark the location of the surgical site])
Staffing (e.g., reallocating staff, role responsibilities, hiring temporary or permanent staff)